UCLH 2016/17 Annual Plan Narrative

UCLH 2016/17 Annual Plan Narrative Establishing the strategic context annual plan 2016/17 UCLH remain committed to the overall clinical and operational strategy that we set out in our strategic plan submission in June 2014 and again in our 2015/16 annual plan submission: We are focused on the strategic intent of developing three clinical specialist service areas with the potential to become, or remain, world leading over the next few years: cancer services, neurosciences and women s health. We are focussed on delivering excellent core medical, emergency and surgical services to the local population. We are focused on working as system leaders within the local health economy in developing new, integrated care models in a number of key pathways and delivering our cancer vanguard bid to provide truly joined up cancer services across North Central and North East London. Progress against the strategy and next steps for 2016/17 and beyond We have made significant progress across a number of our key strategic initiatives over the past twelve months, all of which are integral to supporting delivery of the organisation s long term vision. The service moves as part of London Cancer reconfiguration have taken place as planned; specialist cardiac services were transferred from the Heart Hospital to Barts Health NHS Trust in May 2015 and the additional specialist cancer work transferred to UCLH in December 2015. The final service to transfer is brain cancer and this will move to the National Hospital for Neurology and Neurosciences (NHNN) in early 2017. The business case for proton beam therapy and clinical facility (known as phase 4) has gained full Governor, Board and Official approval and building work on the new site has commenced. This development, which includes a new short stay surgical centre and specialist cancer inpatient facility, opens in 2019. We have progressed plans to co-locate ENT and dental services from the Eastman Dental (EDH) and the Royal National Throat Nose and Ear Hospitals (RNTNEH) to a state of the art hospital located on the main UCH Campus. Full Business Case approval was received from the Trust Board in July 2015 and building work is set to begin in February 2016 with the development opening in late 2018.. Plans are in place to deliver further operating theatre and inpatient bed capacity to the NHNN on the Queen Square site will progress this year, with the new theatre facilities opening in early 2017. This will enable delivery of the London Cancer reconfiguration of brain cancer, as well as supporting increasing demand in specialist neurosurgery including spinal surgery. We have received funding for year one of our cancer vanguard bid. This is now in partnership with The Royal Marsden and Christie NHS Foundation Trusts. The overall objectives of the Vanguard are to improve access to cancer diagnostics across the sector, set a sector wide standard for chemotherapy provision and concentrating expert radiotherapy in a smaller number of specialist units. Leadership of this national new model of care reaffirms our commitment to supporting the principles set out in the 5 Year Forward View. We have progressed work with our local commissioners and neighbouring trusts to develop integrated pathways for adult and paediatric diabetes, musculo-skeletal services, chronic obstructive pulmonary disease and frail elderly. We are fully engaged with commissioners and local authorities in developing our Sustainability and Transformation Plan. Further detail on this is below. We remain eager and committed to 1

taking a leadership role with other partners in the development of sector wide New Models of Care (such as accountable care organisational development) to help support the drive for whole scale service improvement in the sector.. We continue to work with our system resilience group to reduce unnecessary admissions and delayed transfers of care where possible. We have also developed improved relationships with the local authority and have supported decision making around use of the better care fund. Development of the North Central London Sustainability and Transformation Plan (STP) There is a new requirement to deliver an STP by July 2016. The Trust is working with commissioners and local authorities (LAs) across North Central London (NCL) to develop this in line with the expectations set in the 2016/17 planning guidance. This 2016/17 plan is aligned as much as is possible at this early stage with the STP. The STP will encompass work already in train to deliver the ambitions set out on the five year forward view, including delivery of integrated pathways in MSK, COPD, frailty and diabetes; and our cancer vanguard, which proposes a sector wide approach to improve cancer diagnosis and treatment. The STP requires the trust, CCGs and LAs to work together much more closely, and the diversity of populations across NCL does present challenges. However, there has been progress in setting up the structures that will develop the STP and agreeing the themes and high level objectives of the plan. The five CCGs are already taking part in a collaboration programme which has drawn heavily on the work of the consultancy Carnall Farrar. The programme is designed to lead to a much more coherent strategy and set of improvement work across the CCGs. They have put in place a programme management office (PMO). The collaboration board PMO is leading the development of the STP. The PMO consists of a senior programme lead and assistant. They hold oversight for a number of different work-streams in place to lead on different elements of the STP. The work that Carnall Farrar has undertaken for the NCL CCGs has formed the basis for certain aspects of the plan, including the financial base case document, setting out an agreed view of the financial challenge the programme governance framework a high level strategic financial framework and case for change a detailed 2 year plan describing a programme of work shaped around 7 proposed strategic priorities: 1. Transforming urgent and emergency care 2. Transforming care for those with severe and enduring mental illness (SEMI) 3. Primary Care Transformation: developing an enhanced offer 4. Care for those in child and adolescent mental health services (CAMHS) 5. Care for those with chronic complex needs 6. Optimising the use of the estate 7. Prevention and self-care: better health for North Central London Out of the original seven areas of work, the programme has prioritised four areas for delivery in phase one of the transformation portfolio: 2

1. Acute services redesign: with an immediate focus on urgent and emergency care which requires an agreed view about the provider landscape in NCL. 2. Mental health: with an immediate focus on transforming inpatient care 3. Pathways: with an immediate focus on primary care, having common standards and reducing variation 4. System wide enablers: with an immediate focus on estates Recent events have also highlighted the need for the following to be at the heart of the STP: culture and organisational structure fundamental re-design in workforce / relationships between organisations and professional groups communication / engagement on patients and public in health and social services As a trust, we want to play a significant leadership role in the development of the STP and to draw on the wealth of clinical expertise within the organisation to support this. We are already very engaged at the executive level and are in the process of determining the structures and personnel within the trust that will work closely with the sector PMO on delivery. We will also ensure that we are engaged with (although at a higher level) the development of the North West London STP. 1. Corporate Operational Objectives for 2016/17 Each year the Trust Board agree a set of corporate operational objectives. These are based around UCLH s five strategic objectives. The annual corporate objectives for 2016/17 are in development but not yet agreed, with consultation planned with staff and governors. They will go to the Trust Board in April for sign-off. The following diagram summarises these objectives. Once agreed, these will be monitored through the trust s performance framework and there will be a comprehensive quarterly update on progress to the Trust Board. The aim is for them to be tangible, measurable improvements that align to our strategic direction. 3

VISION We are committed to delivering top-quality patient care, excellent education and world class research. VALUES Safety We put your safety and wellbeing above everything Kindness We offer you the kindness we would want for a loved one Teamwork We achieve through teamwork Improving We strive to keep improving STRATEGIC AND ANNUAL OBJECTIVES Provide the highest quality of care within our resources Improve patient pathways through collaboration with partners Support the development of our staff to deliver their potential Achieve financial sustainability Generate worldclass clinical research Deliver Sign up to Safety campaign pledges so that we further reduce harm to patients Meet A&E waiting time targets Improve staff experience Achieve financial targets Achieve redesignation as an NIHR biomedical research centre Maintain upperdecile Standarised Hospital Mortality Index results Meet 18 week and diagnostic waiting times targets Improve development opportunities for staff Contribute to North-Central London s sustainability and transformation plan Increase recruitment of patients into portfolio studies and early phase trials Maintain patient experience ratings Meet cancer waiting times targets Achieve targets for staff retention, vacancies and temporary staffing usage Deliver agreed contracts with commissioners Support bids for the national dementia research institute and the Cancer Research UK centre Improve booking and correspondence with patients and GPs Implement the cancer vanguard project Support assurance of the quality of patient safety through mandatory training completion Improve utilisation of beds, theatres, imaging and outpatient resources Establish new clinical research facility in new location Ensure that we check and action all patient test results Deliver phase 4, phase 5, ED and Queen Square development milestones Improve the quality of appraisals for our staff Progress the rationalisation of support services Deliver on our responsibilities for the 100,000 genome project Achieve hospital acquired infection targets Work with CCGs on new pathways for diabetes, MSK and frail elderly patients Improve the UCLH experience for doctors and dentists in training Agree preferred option for future IT infrastructure Progress clinical academic appointments with UCL 4

2. Quality priorities This section provides further detail on our corporate objective to improve quality and to deliver our Sign up to safety objectives. We will build on our strong track record on the quality of the services that we provide to our patients: Some of the best mortality figures in the country Good performance on key indicators such as pressure ulcers and incidents with harm Positive feedback from our patients through surveys We continue to see areas where we can further improve the quality of services. Doing all we can to keep patients safe is a critical part of our mission to provide top quality patient care. Our quality priorities for 2016/17 are as follows: Priority 1: Patient Experience We will improve overall patient experience as measured by the Friends and Family Test question. We will improve patient experience in priority areas as measured by local and national surveys in selected inpatient outpatient and cancer areas. Priority 2: Patient safety To reduce surgery related harm. This priority includes the WHO checklist and will address human factors and other factors that contribute to the never events for incorrect site surgery and retained swabs To reduce the harm from unrecognised deterioration To reduce patient harm from sepsis To Continue to focus on improving Trust wide learning from serious incidents. Priority 3: Clinical Outcomes We will set up a mortality surveillance group and a mortality governance structure. We will continue to measure the mortality indicator SHMI (Summary Hospital-level Mortality Indicator) as one of our measures of success All of the quality priorities (which include sign up to safety priorities) will be monitored via the trust s performance pack which goes to the trust board each month. There is also a more detailed quality and safety pack and a quarterly report against the priorities which is reported to the Quality and Safety Committee. The Quality and Safety Committee is a sub-committee of the board. There are no current quality concerns in place from any external group. We are have just had our CQC inspection which did not identify any immediate concerns. We are compliant with the requirement for each patient to have a named nurse and named responsible consultant visible above their bed. This is being monitored via quality walk rounds which are being undertaken weekly in clinical areas and review all elements of the CQC inspection. Risks to Quality The following are the main risks to quality in the trust. These are listed with their mitigations: 5

Failure to follow up on abnormal results (histopathology and imaging) leading to delayed or missed diagnosis or other harm to patients. New system in place which flags abnormal radiology and pathology results. Standard operating procedures and a detailed implementation plan is in place to facilitate introduction of this change to reporting and build in measures of success. Patients suffering harm through falling. There is a multidisciplinary falls strategy for the trust which is addressing mitigation. This includes a revised falls policy with an increased focus on multidisciplinary falls assessments for individual patients and on training and availability of equipment to assist with prevention of falls as well as post falls care. There is a multidisciplinary falls group including a Darzi fellow working to implement the strategy. Failure to deliver cancer waiting times and the ED four hour target: Medical director led ED performance meetings in place where breaches, near misses and performance are reviewed Comprehensive ED action plan in place that includes department, trust wide flow and system actions Plan to increase ambulatory care capacity from February 2016 A&E redevelopment plan in place Comprehensive cancer waits improvement plan in place covering all tumour sites Medical director led weekly trust-wide cancer PTL and fortnightly improvement task force in place. Clinical harm review of all cancer breaches We are working hard to ensure that the delivery of an ambitious savings plan does not impact on quality. We have therefore set the mandate that before significant organisational changes are agreed (including CIPs) we require a quality impact assessment (QIA) to be considered and if necessary completed. We have a financial recovery PMO in place who will work with the Quality and Safety team to oversee how this can be achieved. The QIA is designed to capture and assess quality changes to healthcare and the impact on the business, staff and patients. It is expected that all changes must first consider the organisational impact before being agreed to avoid detrimental impact on services provided. If a decision is made not to undertake a QIA the Recovery PMO will be required to confirm and log the reasons why the team has not completed a QIA. Three criteria are assessed within each QIA, classified under: Patient safety & experience Clinical effectiveness & performance Staff experience The QIA process uses the same risk management methodology in place in the trust in order to consider and rank the impact of proposed changes. The approved Risk Matrix is assessed based on two factors: The severity of impact The likelihood of occurrence, and 6

5 x 5 Matrix Provides the Grading for Risk Likelih ood Almost Certain - 5 5 10 15 20 25 Likely 4 4 8 12 16 20 Possible 3 3 6 9 12 15 Unlikely 2 2 4 6 8 10 Rare 1 1 2 3 4 5 Risk Level L x C Negligible 1 Minor 2 Moderate 3 Major 4 Consequence (impact/severity) Green Low 1 to 6 Yellow Moderate 8 to 10 Amber High 12 to 15 Red Very high 16 to 25 Catastro phic 5 Once satisfied that all risks have been fairly considered the QIA will require sign off from the work stream owner, Clinical lead, Chief Nurse, and Medical Director. Each QIA provides the opportunity for commentary to be applied to record decisions reached. The Recovery PMO provides oversight to ensure the most relevant and suitable management are engaged to complete and authorise the QIA and will act as point of challenge as and when required. The PMO has responsibility for monitoring delivery of the CIP and QIA in year. We are currently developing the QIA monitoring process and will be able to fully describe this in our April submission. Approach to Quality Improvement In 2015 UCLH launched the UCLH Institute as part of its Trust wide transformation programme. As part of its remit, the Institute is beginning to integrate quality improvement initiatives across the trust, and define the UCLH standard model of quality improvement. Implementation of this methodology is supported by a dedicated Improvement team and an extended faculty of QI coaches and champions. Our staff are encouraged to apply this approach at departmental level through a managed improvement project that has appropriate local senior sponsorship and includes departmental level management and governance. The Institute will provide training and support through the QI programme described above, and through other educational training and activity, including one integrated staff induction programme for every professional joiner. How Quality and Safety is maintained and improved throughout the year: As members of the sign up to safety campaign, UCLH have made 5 pledges to improve quality and safety in the trust over the next two years. Progress on our pledges is monitored closely by the relevant committees set up to deliver the priorities and is overseen by the Board of Directors sub-committee the Quality and Safety Committee. Improvements to quality and safety are driven at local level through the divisional quality and safety groups and at corporate level through the Patient Safety and Risk Steering Group and the Risk Coordination Board as well as the Quality and Safety Committee. There is a strong focus on learning 7

particularly from serious incidents and on sharing learning and improvements through a variety of means including a quality and safety bulletin. QI governance systems: Quality Improvement activity that is discharged through one of the Trust s Transformation Programmes is overseen by the relevant Project Board (e.g. the Right care, right time, right place Programme) which includes senior executive, clinical and managerial representation. Governance of the transformation programme as a whole, which seeks to improve the quality and efficiency of care trust wide, is overseen by the Transformation Steering Group which includes corporate senior Executive, Medical Director and Chief Nurse membership. Trust wide Quality and Safety improvement activities within Sign up to Safety are each governed by an MDT steering group, usually clinically led, with regular progress reports provided to the Quality and Safety Committee and ultimately to the Board of Directors. 3. Priority performance challenges During the past year we have responded to significant challenges in delivering key access targets, in particular the A&E four hour wait and they 62 and 31 day cancer targets Referral to Treatment (RTT) We achieved all RTT targets at trust level in 2015/16 (to date). This is a key achievement of 2015/16 and we feel that following a process of restructure and development we have now built a sustainable platform for providing shorter waits for our patients based on: Clear roles and responsibilities for the delivery of short waiting times More rigorous patient target list (PTL) meetings at all levels of the organisation, ensuring more proactive operational management of waiting lists Greater discipline in booking patients according to protocols that are shown to deliver shorter waiting times Significant improvements to our operational reporting capability on patient waiting times, in particular much stronger PTL reporting and far tighter controls around our validation of patient pathway information Specialty level RTT demand and capacity modelling and forecasting. The following is our RTT performance trajectory (this has also been submitted as part of the STP process). Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total patients waiting 32700 32700 32700 32700 32700 32700 32700 32700 32700 32700 32700 32700 Total patients waiting >18 weeks 2200 2200 2200 2200 2200 2289 2354 2420 2485 2583 2583 2583 Performance 93.3% 93.3% 93.3% 93.3% 93.3% 93.0% 92.8% 92.6% 92.4% 92.1% 92.1% 92.1% No. 52 week waiters 0 0 0 0 0 0 0 0 0 0 0 0 This assumes the level of referrals remains broadly in line with plan. The reduction in performance in the autumn reflects the potential impact of reduced capacity on our Queen Square site as a result of theatre refurbishment and also the impact of winter pressures in the last 4 months of the year. Whilst we are not predicting any 52 week waiters we should not be penalised for single or small instance events. 8

Diagnostic Waits We have missed the 99% standard each month in 2015/16. All areas should be recovered by the start of 2016/17 apart from endoscopy and MRI at our queen Square site. We have undertaken demand and capacity analysis in both of these areas and have recovery trajectories in place. The endoscopy department has been expanded following refurbishment works so does have increased capacity. However, there are London wide shortages of trained nursing staff which has limited our ability to increase capacity. We are currently utilising outsourcing to a private hospital and to the Whittington and weekend and evening lists (where they can be staffed) to clear the backlog. The current trajectory is for achievement in July. MRI have seen an increase in demand. They have contracted a mobile scanner for four weeks in February and March and expect to reach compliance in April. We are reviewing our diagnostic waits management processes to ensure that the same focus and rigour that we now have for RTT management is applied at all levels of the trust. The following is our diagnostic performance trajectory (this has also been submitted as part of the STP process). Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total patients waiting 7539 7539 7539 7539 7539 7539 7539 7539 7539 7539 7539 7539 Patients waiting < 6 weeks 300 225 175 75 75 75 75 75 75 75 75 75 Performance 96.0% 97.0% 97.7% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% This is based on the activity levels stated. If demand increase beyond this then performance may be impacted. Cancer Waits We have missed the 62 day standard each month in 2015/16 and also missed the 31 day standard in a number of months. We also missed the 14 day standards, particularly in the later months of the year on account of sudden staff shortage in our breast service. We have taken some key steps to improve our position against all of the cancer targets. In areas where we are fully in control of pathway and process improvements we have: Put in place medical director-led PTL meetings for all cancer pathways Improved the breach analysis process we have in place for pathways at our hospitals to understand what is driving delays. We are reviewing these breach analysis in collaboration with commissioners to help ensure a much greater system wide approach to improvement Developed timed pathways which show the milestones that need to be met for each pathway to be compliant with the 62 day standard and structured a clear performance framework and accountable lead for each element of the pathway and compliance with standards Delivered pathway re-design to shorten pathways including one stop clinics in urology prostate and currently piloting straight to test in lower GI. Put in place additional capacity where required; examples include: urology robotic surgery, head and neck ultra-sound and skin two week wait clinics. Carried out detailed analysis of two week wait capacity and availability on choose and book in order to reduce the number of breaches as a result of patients choosing slots outside of the two week standard. Improved the resilience of the breast service through additional appointments We continue to play a system leadership role across the London Cancer area. For example we host the Cancer Unification Board and facilitated a sector wide prostate pathway task and finish group. We hope to further work with our referring trusts in 2016/17 to shorten waits in the early stages of the pathway. The trust s cancer vanguard bid will also deliver improved cancer pathways through more joined up networks of care across North East and North Central London. 9

We are likely to continue to face some pressures on waits at various stages on our cancer pathways. We believe our focus on two week wait capacity will reduce the number of patient choice breaches, but we are concerned that patient choice will remain a risk on this part of the pathway. We have a number of very highly specialised services (such as HIFU) where we need to put in place plans for resilience in the case of sudden lost capacity due to staff shortages; while we don t envisage significant risk to the 31 day standard at this point, our final plan will provide a more definitive position. On the 62 day standard, like all major tertiary centres our future continued compliance remains dependent upon partner trusts delivering improvements on their stages of patient cancer pathways. The following is our 62 day performance trajectory (this has also been submitted as part of the STP process). Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total patients treated 60 60 60 61 61 61 62 62 62 63 60 63 Total patients treated in more than 62 days 20 16 14 12 11 11 9 9 9 9 9 9 Performance 66.7% 73.3% 76.7% 80.3% 82.0% 82.0% 85.5% 85.5% 85.5% 85.7% 85.0% 85.7% This is based on the assumption that the number of late referrals reduces to 15% across the period to end September. This reduction in turn is dependent upon: a) the continued collaboration of all relevant organisations in the redesign of pathways to shorten the time taken for trusts to refer to UCLH as the tertiary centre b) the commitment of referring trusts to trajectories that 95% of onward referrals are made to tertiary centres within 31 days of GP referral. Tertiary centres will in turn commit to the standard that these cases are treated within 31 days of receipt of referral. This trajectory also assumes that total treatments remain steady; there are risks to performance in months when the overall treatment denominator drops. This trajectory is based on the current performance rules, if the proposed breach reallocation protocol is implemented during the period then performance will change. A&E Four Hour Wait Along with most other trusts nationally, we have not consistently met the operational standard that 95% of our patients are seen in our emergency department within four hours. We have however performed better than the average for London and nationally, particularly between March and July 2015. We have progressed actions across the pathway of urgent care and made some improvements in reducing the number of delays over four hours that are within the remit of the emergency department itself. Bed availability in the tower continues to impact on performance. Key actions during 2016/17 will be to secure the capacity required to deliver against all access targets and improve the consistency of practice across the urgent care pathway. We have also made good progress in the past year in working with CCGs, community providers, mental health and social care colleagues as part of our system resilience group to address the system wide factors impacting flow. Improvements from this group include development of a system wide scorecard to monitor pressure across the whole system, increased commissioning of step down capacity and improved mental health crisis support. In 2016/17 we will continue to progress work through the SRG and to work more closely with the local authority to help allocate priorities for the better care fund. Key deliverables will be: Embedding an admission avoidance service and a redirection service into our ED. Significantly expanding the size of the department to provide increased space for ambulatory care pathways and clinical decision unit. This will support both achievement of the four hour wait and maintain our already very low conversion rate from ED attendance to admission. Increase usage of our UCLH@Home service to facilitate earlier discharge from the hospital therefore releasing bed capacity Use of a 10 bedded step down ward in the community, which as capacity to flex up to 17 beds, pending recruitment of sufficient staffing 10

Whilst we expect all of these to have a positive impact on our performance, there is likely to be risk to our A&E performance across the year as a result of our ED development work and any further increases in A&E attendances and increased complexity of admissions. Between now and our final plan submission we will do more work to quantify the scale of this risk. We have not yet completed the template on performance standards pending further assessment of risks and the role that commissioners need to play in relation to our performance against the cancer and A&E performance standards. The following is our ED performance trajectory (this has also been submitted as part of the STP process). Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total patients seen 10979 11016 11053 11140 11127 11214 11251 11238 11325 11312 11399 11437 Total patients who wait more than 4 hours 1320 1000 800 557 556.35 560 560 800 700 800 900 900 Performance 88.0% 90.9% 92.8% 95.0% 95.0% 95.0% 95.0% 92.9% 93.8% 92.9% 92.1% 92.1% This is based on the following assumptions: -Predicted activity levels. If attendances increase beyond this then performance may be impacted. -Current performance at neighbouring trusts. If this drops then there will be resultant impact on our performance. The period of non-compliance in April, May and June is to reflect the scale of improvement that we need to achieve from our current performance level. -The dip from November reflects tight bed demand / capacity from our bed modelling. -We are undertaking works to increase the footprint of our ED. Whilst these are ongoing they will impact on departmental space and some flows UCLH is one part of a broader urgent care system that has faced very significant challenges across 2015/16. Current System Resilience Group plans have had an impact in mitigating the impact of rising demand for urgent care services, and we will continue to work with partners in making these system plans more robust and fit-forpurpose. Triangulation of indicators and monitoring quality and performance We will also measure quality through triangulation of different indicators, including workforce, financial, quality and efficiency. The trust s main tool for doing this is through its performance assurance strategy, which is shown in the following diagram: 11

This framework enables detailed review of performance against metrics and monitoring delivery of any recovery actions. This is then fed up to the Trust Board and Quality and Safety Committee as part of detailed performance and quality packs which includes all elements of a balanced scorecard. There is further detail on workforce performance management and assurance in section 5, workforce planning. 4. Approach to Activity and Capacity Planning Activity planning is a bottom up process that is undertaken by divisions and collated centrally by the corporate planning team. This year we have also worked much more closely with CCG commissioners to get to a joint position on the activity plan. This year, more corporate support had been provided to inform the activity planning process; Demand and capacity modelling had been undertaken in challenged RTT specialties, diagnostic pathways and two week wait tumour sites to identify the level of activity required to deliver access standards. The outputs from these were shared with commissioners. The head of planning and performance ran two activity planning sessions for divisions and central data was provided on population growth and on referral trends We have also improved the challenge process for testing that activity plans were reasonable, evidence based and sufficient to deliver access standards. There were significant strategic changes and service moves which took place in 2015/16. We have therefore shown growth both on 2015/16 forecast out turn, and on the 2015/16 quarter four times four position. This gives a better picture of real growth excluding major service moves. At a trust level we are planning for growth against all points of delivery as follows: 12

UCLH total 15/16 Q4 FOT and 16/17 Plan Revised plan growth 1516Plan 1516FoT 1516Q4 1617Plan 1516FoT 1516Q4 A&E 128,501 134,648 132,160 134,441 0% 2% Day Cases 96,869 98,238 103,204 108,599 11% 5% Electives 25,261 24,037 25,294 25,126 5% -1% First Attendances 252,581 248,515 257,655 258,834 4% 0% Follow-up Attendances 736,892 764,771 755,137 797,249 4% 6% Total NonElective 60,842 54,114 55,654 56,857 5% 2% Growth in non-elective slowed down in 2015/16, and the 2016/17 plan follows this trend. Elective growth has also slowed on last year; unlike in 2015/16 we are not starting the new year with significant volumes of non-compliant RTT waiting lists. There is significant day case growth, and this is evident across a number of specialties; including trauma and orthopaedics, GI surgery and medicine, cancer and dermatology. Follow up attendances growth is disproportionately higher than first attendance growth; this is in part attributed to the move to more one-stop and straight to test pathways in urology and GI. We feel that we are aligned with Camden CCG on most areas of activity planning. There is some variance to our forecast outturn (FOT) position on outpatients but this reflects two things: -UCLH have based the latest FOT on actuals whereas the CCG are using figures supplied to them from NHSE based on M9. -The activity numbers supplied to Camden did not include neurology and max fax outpatient activity because these are being moved from specialist to local commissioning for 2016/17. UCLH and Camden growth assumptions are aligned on all points of delivery. In 2016/17 we will be moving to implementing a rolling 12 month forecast. This will help us to improve our activity planning capability through the year and to better understand the drivers for changes to activity. It will also ensure that we do not artificially plan for an artificial step change in activity which can sometimes result from an annualised process. Bed and theatre capacity management As in previous years, we have used the outputs from the activity plan to inform our trust-wide demand models. These show the level of beds, theatre sessions and diagnostic imaging required to deliver the activity plan. The following chart shows the output of our bed modelling at our UCH site. The pale blue background is our bed capacity, whilst the purple line shows bed demand each month. In months ten, eleven and twelve there is insufficient bed capacity to deliver planned activity. 13

We have included some mitigation within the bed modelling. These are known schemes that will deliver additional bed capacity. They include: Increased use of the Hospital@Home service Use of a 10 bedded step down ward in the community Expansion of our ambulatory care service We will look to introduce further mitigations into our plan for quarter four. Likely schemes include: Length of stay efficiencies, which will be delivered through the urgent and elective pathways work as part of UCH Future, our transformation programme Basing a community admission avoidance team in ED to support patient care in their own homes This year we are not projecting capacity pressures in our theatres through most of the year. However, Queen Square is undergoing a theatre refurbishment work in quarter four of 2016/17. We are currently considering options to maintaining activity during this period which may involve outsourcing some activity. Imaging capacity has been challenged, particularly in endoscopy and MRI where we have been noncompliant with the six week wait standard. We have undertaken detailed demand and capacity modelling in endoscopy, and are currently utilising these models to track recovery against the standard, and to inform service changes to deliver sustainable performance. In MRI, we have more recently completed demand and capacity modelling. The outputs from these will be used to inform decisions around future service efficiencies and developments. One of our key challenges in 2015/16 has been our ability to respond to unplanned changes in demand. This has been both when we have more demand than expected and less. One of the key programmes within our transformation programme is to implement a full functional co-ordination centre which will manage all elements of site operations. It will be supported by real time information on bed states and an operational modelling tool to predict demand over the next six weeks. This central team should therefore be able to improve decision making about how to use capacity in the immediate to short term horizon. 14

5. Workforce Planning Our approach to Workforce Planning Workforce planning is led through our clinical boards, supported by their embedded HR and finance leads. This process ensures that workforce plans are consistent with the trust and clinical board service strategy, affordable and informed by the aligned plans of partners including local NHS trusts and our new vanguard partners. Examples of this include the work we have undertaken with Health Education England (HEE) to ensure that the training numbers in radiography are sufficient to deliver the demands of proton beam therapy. Likewise we are currently managing the workforce impact of moving services at the Eastman Dental Hospital and the Royal National Ear, Nose and Throat Hospital into a new, world-leading centre for the diagnosis and treatment by 2018. Our streamlined planning process aligns with the workforce planning requirements of the Local Education and Training Board so we can support HEE make robust commissioning decisions for the future NHS workforce. Systematic reviews and checks have been built into the workforce planning process: Board-level workforce plans will be triangulated with the activity and finance plans and approved by the relevant Clinical Board before they are put forward to be integrated into the Trust-level workforce plan There will also be a central-review of the Clinical Board workforce plans to check for consistency with the overall Trust service strategy As part of this review, any CIP that has a workforce impact will be subject to the QIA process described earlier. Workforce Performance Management Workforce reporting forms an integral part of Trust performance management review to enable the triangulation of quality and safety metrics with workforce indicators to identify any areas of risk: There is a workforce section in the monthly CEO performance pack, which reviews key workforce indicators such as our vacancy and turnover rates; temporary staffing utilisation; sickness; appraisal; mandated training compliance. There is a clear evidence base showing correlation of performance on these workforce indicators with quality and safety outcomes for our patients. Workforce indicators are also reviewed as part of the Commissioning Quality Review Group meeting, which is a partnership meeting with our Commissioners to provide clinical review of the quality schedule within the Trust s contract. Commissioners have sought in depth analysis on work that is helping us improve and sustain improvements for our current and future staff. Workforce performance is also monitored within the regular Transformation Strategy Group meetings that have been instigated to ensure that the Trust is able to maintain its service priorities whilst maintain financial control. Our equality and diversity steering group have informed regular reviews of our performance against the workforce race equality standard. Within this forum, workforce indicators are reviewed alongside finance and activity performance. Workforce Quality Risks When we enter 2016/17 we expect our vacancy rates to be significantly below the London average and for temporary staffing supply to be within the cap and target levels set by NHS Improvement. We intend to focus on three key themes of work that shall help us achieve workforce transformation. 15

Productive people: we intend to apply tests guided by Carter s interim and pending full report - so that revised process design informs more efficient and effective role and organisational design and that we drive forward work on medical productivity (supported by the introduction of a electronic medical utilisation, job planning and appraisal system). Well employed people: we intend to take opportunity to ensure we apply common models of employment contracting that allow for portable employment across the sectors in which we work (e.g. as define in the value proposition of our cancer vanguard); and achieve optimal value from professional groups for which new contracts are set (e.g. junior doctors); or we may allow for more economic staffing (e.g. mandated apprenticeship growth to replace administrative and clerical roles). Motivated people: we shall act on our staff survey results (from the October 2015 survey) and related staff expectation to renew our support for staff. One element of this work shall be a new reward and recognition framework. We have made good progress through our aligned organisational development work to accelerate capability development amongst our leaders, through; Our new leader development programme: 55 attendees by the end of January 2016 target is 250 by end 2016/17 Change capability 50 attendees by the end of January 2016 target is 200 by end 2016/17 The Organisational Development team has also completed a change diagnostic and engagement planning exercise with the Care Delivery System project leads and challenged divisions - the outputs of which are being integrated into the program leads work plans. E-rostering and Exemplar As part of UCLH s transformation programme, a 12 month project is ongoing to realise greater benefits from our e-rostering tool. This work will standardise practices across wards and clinical departments to ensure that staff are rostered in such a way as to reduce reliance on temporary staffing and maximise efficient working patterns. In addition, effective rostering coupled with use of a patient 1-1 care prescription tool is predicted to release further efficiency savings through a reduction in specialing of patients. Seven Day Services In August 2015, Monitor, TDA and NHS Improving Quality issued a communication stating that four of the ten 7 Day clinical standards were now seen as priorities. These four standards were considered to have the most impact on reducing weekend mortality, based on discussions with the Academy of Medical Royal Colleges. Standard 2 - Time to First Consultant Review Standard 5 - Diagnostics Standard 6 Intervention/Key Services Standard 8 - On-going review In line with timeframes, UCLH completed a baseline assessment against the 4 priority standards at the end of August 2015 and the remaining 6 clinical standards at the end of September 2015. The assessment demonstrated that UCLH met the standards in most areas and are already providing a safe and effective service against the key four standards. Compliance with standards relating to patients on an urgent care pathway is robust. It is noted that the standards touch on all inpatient care and not only the urgent care pathway. 16

The assessment is being used to inform areas for further improvement and an action plan is being developed on this basis to be presented to the Clinical Quality Review Group in March 2016. UCLH intend to take forward the relevant case note reviews under clinical leadership in relation to the four key priorities. 7 Day Care has been incorporated into the UCLH Future Programme through our Urgent Care Programme. 17